Provider Demographics
NPI:1821135831
Name:MILTON J GROSENBACH EDD, PC
Entity Type:Organization
Organization Name:MILTON J GROSENBACH EDD, PC
Other - Org Name:THE CENTRE
Other - Org Type:Other Name
Authorized Official - Title/Position:DR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GROSENBACH
Authorized Official - Suffix:JR
Authorized Official - Credentials:EDD PC
Authorized Official - Phone:810-678-8898
Mailing Address - Street 1:3562 S LAPEER RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:METAMORA
Mailing Address - State:MI
Mailing Address - Zip Code:48455-8998
Mailing Address - Country:US
Mailing Address - Phone:810-678-8898
Mailing Address - Fax:810-678-8808
Practice Address - Street 1:3562 S LAPEER RD
Practice Address - Street 2:SUITE F
Practice Address - City:METAMORA
Practice Address - State:MI
Practice Address - Zip Code:48455-8998
Practice Address - Country:US
Practice Address - Phone:810-678-8898
Practice Address - Fax:810-678-8808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003782103T00000X
MI4101005216302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M43200OtherMEDICARE ID
MIOD41119OtherBLUE CARE NETWORK
MI0D41076OtherBLUE CROSS BLUE SHIELD
MI620G44601OtherHEALTH PLUS